Cimetidine repurposed as a potential immunomodulatory agent against colorectal carcinoma: A systematic review.

OBJECTIVE: To determine the survival benefit and immunomodulatory effects of cimetidine pre-, peri- or post-operatively in patients with colorectal cancer (CRC). METHODS: A systematic review was conducted using PubMed and Cochrane Library to retrieve randomized control trials (RCTs) that investigated the effects of cimetidine on survival and immunomodulation via improvement in tumor infiltrating lymphocytes (TILs) and peripheral blood lymphocytes. The review was carried out in accordance with the extended Preferred Reporting Items for Systematic Reviews and Meta-analyses. RESULTS: Four studies with the total of 267 patients were included in this systematic review. Treatment duration varied from 5 days to 1 year. Two studies reported a significant TIL response in the resected specimens after administering cimetidine, while one RCT showed an escalation of CD3, CD4 and CD57 lymphocytes in peripheral blood compared to the baseline following cimetidine treatment (p < 0.01). Of the three trials that examined the effects of cimetidine on survival, only two studies revealed significant survival benefit while the remaining study only showed a trend towards survival benefit. CONCLUSION: Repurposing of existing drugs like cimetidine has a potential to offer a survival benefit by acting as an immunomodulatory agent in patients undergoing curative resection for CRC. However, the heterogeneity seen in current studies and the evolvement of adjunctive therapies for CRC warrant large-scale, well-designed prospective RCTs to establish the efficacy of cimetidine in CRC.

Caregiver strain among patients of palliative care in Sri Lanka: validation of modified caregiver strain index - Sinhala version.

BACKGROUND: Care givers of Palliated patients are at risk of adverse physical, psychosocial and emotional sequelae in varied nature. Efficient and valid assessment tools facilitate early detection to take corrective measures. The Modified Caregiver Strain Index (MCSI), composed of domains associated with caregiver strain is a simple and brief tool that can be used in both clinical and field settings. This study aimed to adapt and validate this in order to cater effective palliative care services in Sri Lanka. METHODS: After cross-cultural adaptation, 200 primary caregivers in 3 teaching hospitals were recruited. The internal consistency, item-total correlations, of the 13-item S-MCSI were performed. The criterion validity was assessed by Pearson correlation between the total scores of S-MCSI, the Karnofky Performance Scale and the Barthel index. Construct validity was determined by the principal component analysis keeping the Varimax with Keiser normalization as the rotation method. The Kaiser-Meyer-Olkin test (KMO) and Bartlett's test of sphericity statistics were also performed to determine the adequacy of the sample and correlations between items, respectively. The number of factors was determined by the Scree plot, percentage of variance explained by each component and number of Eigen values over 01 (Kaiser-Guttman rule). RESULTS: The total MCSI score ranged 0 to 26. The overall Cronbach's alpha of the 13-item questionnaire was 0.80 while item-total corrections ranged 0.34 to 0.62, exception of one item (0.11). Inverse correlations were demonstrated in total scores of MCSI and Karnofky Performance Scale (r =- 0.32, p < 0.001) and Barthel index (r =-0.34, P < 0.001). A Kaiser-Meyer-Olkin value of 0.79 (p < 0.001) for Bartlett's test indicated adequate sampling and nonlinearity of factors. The Scree plot showed a three-factor structure explaining 57% of the variation. Items regarding personal wellbeing of caregiver loaded together while the effects on the family loaded separately. Adjustment of personal concerns and family issues along with time alteration grouped as the third factor. CONCLUSIONS: The study showed that the Sinhala version of MCSI has adequate psychometric properties and reliability to be used as a validated tool to estimate the caregiver burden within a short time period for any health care workers.

Development of the Asia Pacific Consortium on Osteoporosis (APCO) Framework: clinical standards of care for the screening, diagnosis, and management of osteoporosis in the Asia-Pacific region.

Guidelines for doctors managing osteoporosis in the Asia-Pacific region vary widely. We compared 18 guidelines for similarities and differences in five key areas. We then used a structured consensus process to develop clinical standards of care for the diagnosis and management of osteoporosis and for improving the quality of care. PURPOSE: Minimum clinical standards for assessment and management of osteoporosis are needed in the Asia-Pacific (AP) region to inform clinical practice guidelines (CPGs) and to improve osteoporosis care. We present the framework of these clinical standards and describe its development. METHODS: We conducted a structured comparative analysis of existing CPGs in the AP region using a "5IQ" model (identification, investigation, information, intervention, integration, and quality). One-hundred data elements were extracted from each guideline. We then employed a four-round Delphi consensus process to structure the framework, identify key components of guidance, and develop clinical care standards. RESULTS: Eighteen guidelines were included. The 5IQ analysis demonstrated marked heterogeneity, notably in guidance on risk factors, the use of biochemical markers, self-care information for patients, indications for osteoporosis treatment, use of fracture risk assessment tools, and protocols for monitoring treatment. There was minimal guidance on long-term management plans or on strategies and systems for clinical quality improvement. Twenty-nine APCO members participated in the Delphi process, resulting in consensus on 16 clinical standards, with levels of attainment defined for those on identification and investigation of fragility fractures, vertebral fracture assessment, and inclusion of quality metrics in guidelines. CONCLUSION: The 5IQ analysis confirmed previous anecdotal observations of marked heterogeneity of osteoporosis clinical guidelines in the AP region. The Framework provides practical, clear, and feasible recommendations for osteoporosis care and can be adapted for use in other such vastly diverse regions. Implementation of the standards is expected to significantly lessen the global burden of osteoporosis.

IQ driving QI: the Asia Pacific Consortium on Osteoporosis (APCO): an innovative and collaborative initiative to improve osteoporosis care in the Asia Pacific.

Asia Pacific Consortium on Osteoporosis (APCO) comprises of clinical experts from across the Asia Pacific region, uniting to develop solutions to problems facing osteoporosis management and care. The vision of APCO is to reduce the burden of osteoporosis and fragility fractures in the Asia Pacific region. INTRODUCTION: The Asia Pacific (AP) region comprises 71 countries with vastly different healthcare systems. It is predicted that by 2050, more than half the world's hip fractures will occur in this region. The Asia Pacific Consortium on Osteoporosis (APCO) was set up in May 2019 with the vision of reducing the burden of osteoporosis and fragility fractures in the AP region. METHODS: APCO has so far brought together 39 clinical experts from countries and regions across the AP to develop solutions to challenges facing osteoporosis management and fracture prevention in this highly populous region of the world. APCO aims to achieve its vision by engaging with relevant stakeholders including healthcare providers, policy makers and the public. The initial APCO project is to develop and implement a Framework of pan-AP minimum clinical standards for the screening, diagnosis and management of osteoporosis. RESULTS AND CONCLUSIONS: The Framework will serve as a platform upon which new national clinical guidelines can be developed or existing guidelines be revised, in a standardised fashion. The Framework will also facilitate benchmarking for provision of quality of care. It is hoped that the principles underlying the formation and functioning of APCO can be adopted by other regions and that every health care facility and progressively every country in the world can follow our aspirational path and progress towards best practice.

Cutoff values for the determination of sarcopenia and the prevalence of the condition in middle-aged women: A study from Sri Lanka

Introduction: There is a scarcity of studies related to sarcopenia in Sri Lanka. This partly is due to lack of cutoff values to define muscle mass, strength and physical functions. Objective: This cross-sectional study determined the cutoff values of sarcopenia measures and evaluated the prevalence of sarcopenia among middle-aged Sri Lankan women. Method: A reference group of 117 young women (20-40 years) was used for cutoff value determination. The prevalence of sarcopenia was estimated among a group of 270 women (41-60 years). Appendicular Skeletal Muscle Mass (ASMM, kg) was measured by DXA and was adjusted for height (ASMM/height2) to determine Relative Skeletal Muscle mass Index (RSMI, kg/m2). Hand Grip Strength (HGS, kg) and Gait Speed (GS, m/s) were also measured. Cutoff values for measures of sarcopenia were taken as 2SD below the mean value of the young reference group. Result: Mean(SD) ages of the participants; young reference group and middle-aged group were 35.5(3.8) and 52.2(5.8) years respectively. Cutoff values for the main three measures of sarcopenia; RSMI, HGS and GS were 5.03kg/m2, 9.66kg and 0.96m/s respectively. Prevalence of pre-sarcopenia, sarcopenia and severe-sarcopenia among middle-aged women were 3.0%, 2.2%, 0.7% respectively. The corresponding values among postmenopausal women were 4.2%, 3.0%, 1.2% and among premenopausal women were 1.0%, 1.0%, 0.0%. Prevalence of sarcopenia was higher among women aged between 51-60 years and severe sarcopenia was observed only in this age group. Conclusions: This study provides cutoff values for the measures of sarcopenia for Sri Lankan women. Prevalence was higher among postmenopausal women compared to premenopausal women.

Performance of Sri Lankan FRAX algorithm without bone mineral density and with Quantitative Ultrasound data input

Introduction: Fracture risk assessment algorithm (FRAX) is the most validated method available to predict fracture risk. Its use is restricted due to limited availability of Dual Energy X-ray Absorptiometry (DXA). FRAX has the option of assessing facture risk without BMD data. Objectives: To assess the ability of Sri Lankan FRAX algorithm without BMD input in evaluating fracture risk. The possibility of replacing the BMD input with Quantitative Ultrasound (QUS) data of radius in calculating fracture risk also assessed. Method: Data of clinical risk factors associated with fractures were collected from community dwelling postmenopausal women (n=339). DXA scans were performed in all subjects and QUS scans (in radius) were performed in a randomly selected sample (n=207). Ten-year risks of major osteoporotic fracture (MOFR) and hip fracture (HFR) were calculated with BMD, without BMD (FRAX-FN0) and with US T score instead of BMD (FRAX-UST). Result and conclusions: Nearly 35.7% had high risk of fractures. FRAX-FN0 had 79.2% sensitivity, 80.1% specificity, 68.8% positive predictive value (PPV) and 87.4% negative predictive value (NPV). FRAX-UST showed 78.4% sensitivity, 70% specificity, 59.8% PPV and 85% NPV. ROC AUCs were above 0.80 in both FRAX-FN0 and FRAX-UST. The standard errors of estimate (SEE) were less in FRAX-FN0 (3.96 and 2.76 for MOFR-FN0 and HFR-FN0 respectively) compared to FRAX-UST (6.13 and 4.83 for MOFR-UST and HFR-UST, respectively). In conclusion, Sri Lankan FRAX without BMD is an acceptable alternative in areas with restricted DXA facility. Radial QUS data cannot be used as a substitute to FN-BMD in Sri Lankan FRAX.

Effect of Vitamin D therapy on urinary albumin excretion, renal functions, and plasma renin among patients with diabetic nephropathy: A randomized, double-blind clinical trial.

BACKGROUND: Despite different management strategies, progression of proteinuria occurs in a sizable category of patients with diabetic nephropathy (DN). Increase in serum renin levels induced by the renin-angiotensin system (RAS) may contribute to this. Vitamin D therapy is found to have an inhibitory effect on the RAS. We aimed to study the effects of Vitamin D therapy on renal functions of patients with DN. METHODS: This was a double-blind, randomized, placebo-controlled study. Patients with DN (urinary albumin [UA] >30 mg/g of creatinine) whose estimated glomerular filtration rate (eGFR) was more than 30 mL/min were selected and their plasma renin, parathyroid hormone, serum Vitamin D, serum calcium, serum creatinine, fasting blood sugar were done as baseline measurements. Subjects were randomized into two groups and treatment group was given Vitamin D, 50000 IU (0.25 ml) intramuscularly (IM) monthly for 6 months; control group received distilled water IM. Investigations were repeated after 6 months of therapy. RESULTS: Of 155 patients invited, 85 were randomly assigned to two groups. After 6 months, mean reduction of UA to creatinine ratio in the treatment and control group was 51.8 mg/g (95% confidence interval [CI]; 66.1--37.5, P ≤ 0.001); 22.4 mg/g (95% CI; -45.7-0.8, P = 0.06), respectively (between group difference P = 0.001). Significant increase in the eGFR observed in the treatment group while eGFR remained unchanged in the control group (P = 0.03 for the between-group difference). Mean reduction in plasma renin in treatment group and control group was 5.85 pg/mL (95% CI; -6.7--4.6) (P < 0.001) and 0.95 pg/mL (95% CI; -1.4--0.14, P = 0.02), respectively. CONCLUSIONS: Vitamin D 50000 IU given IM monthly for 6 months reduces urine albumin, serum creatinine, and renin levels in patients with DN.

Concordance between measured and estimated appendicular muscle mass in adult females.

This study assessed the accuracy of a selected formula used to estimate the appendicular muscle mass (AMM) which is linked with many clinical outcomes. A group of community-dwelling adult women (n=80) had their AMM measured using dual energy x-ray absorptiometry (DXA). The same was estimated using a formula already published {Skeletal muscle mass = (0.244 × BW in kg) + (7.80 × Ht in meters) + (6.6 × Sex) - (0.098 × Age) + race - 3.3} (sex=0 for female and 1 for male, race =-1.2 for Asian, 1.4 for African American and 0 for White and Hispanic).The two datasets were compared for accuracy and precision. Mean AMM measured by DXA and estimated by the formula were very close (14.8 and 14.5 kg) and the difference ranged from -1.2 to 3.6 kg. Correlation between the two datasets was high (r=0.92) and the Bland-Altman plot showed an acceptable measurement agreement between the two methods. Results were independent of age and BMI. The formula used in this analysis gave an accurate estimation of the absolute AMM in women included in this study.

Evaluating compliance with the care standard of proactively assessing bone health in patients with diabetes: a pilot audit of practice across Asia by the Asia Pacific Consortium on Osteoporosis (APCO).

This pilot audit explored how bone health is assessed patients with diabetes in diverse centres across Asia. Only 343 of 1092 (31%) audited patients had a bone health assessment, 27% of whom were diagnosed with osteoporosis. Quality improvement strategies are needed to address gaps in patient care in this area. PURPOSE: The Asia Pacific Consortium on Osteoporosis (APCO) Framework outlines clinical standards for assessing and managing osteoporosis. A pilot audit evaluated adherence to clinical standard 4, which states that bone health should be assessed in patients with conditions associated with bone loss and/or increased fracture risk; this report summarises the audit findings in patients with diabetes. A secondary aim was to assess the practicality and real-world use of the APCO bone health audit tool kit. METHODS: Eight centres across Asia participated in the pilot audit, selecting diabetes as the target group. Participants reviewed their practice records for at least 20 consecutively treated patients with the target condition. Questions covered routine investigations, bone health assessment, osteoporosis diagnosis, and patient referral pathways. Data were summarised descriptively. RESULTS: The participants represented public hospitals, university medical centres, and private clinics from India, Malaysia, Pakistan, Singapore, Taiwan, and Vietnam that see an estimated total of 95,000 patients with diabetes per year. Overall, only 343 of 1092 audited patients (31%) had a bone health assessment. Osteoporosis was subsequently diagnosed in 92 of 343 (27%) patients. CONCLUSION: Bone health was not assessed in most patients with diabetes. The results provide insight into current practices across diverse Asian centres and demonstrate the practical value of the audit tool kit. Participant feedback has been used to improve the tool kit. Results of this pilot audit are being used in the respective centres to inform quality improvement projects needed to overcome the gap in patient care.

Factors that determine body composition of female systemic lupus erythematosus (SLE) patients in Sri Lanka: a comparative study using dual-energy x-ray absorptiometry.

Studies on body composition and its determinants among SLE patients are limited. Estimation of body composition, analysis of determinants and associations of different body compartments are important in planning long-term care of these patients. The aim of the study was to identify the changes in body composition among SLE patients and assess the effect of corticosteroid use, patient and disease-related variables on body composition. We compared lean mass, fat mass, bone mineral density (BMD), and bone mineral content (BMC) determined by dual-energy x-ray absorptiometry technology, in a group of premenopausal women with SLE (n = 27) and an age-matched healthy group of women (n = 27). The median (IQR) duration of SLE was 3 (2-5) years while median (IQR) duration and dose of prednisolone therapy were 108 (88 - 172) weeks and 9730 (6160-15360) mg, respectively. No significant difference was observed in body mass index (BMI) or total fat mass between the two groups. SLE patients, however, had significantly lower lean mass (p < 0.001), BMD (p < 0.001) and BMC (p < 0.005) than healthy controls. Among cases, compared with lean mass, total body fat content showed stronger associations with total body BMD (r = 0.49, p < 0.01) and total body BMC (r = 0.63, p < 0.01). When a stepwise regression model was fitted, lean mass among controls and total fat mass among cases emerged as the best predictors of BMC/BMD. No significant correlations were found between the disease duration or cumulative glucocorticosteroid dose and total body BMD, total body BMC, lean mass or total fat content in SLE patients.

Validity of BMI, hip and waist circumferences as surrogate measures of obesity in a cohort of Sri Lankan premenopausal women.

INTRODUCTION: BMI, hip and waist circumferences (HC and WC) are being used as clinical surrogates of obesity. Unceratinities exist regarding the cut-off values, which are recommonded for Western countries. OBJECTIVES: We conducted a study to determine cut-off values for Sri Lankan women. METHODS: Healthy premenopausal women (n=128) aged 25 to 50 years were selected randomly, from local MOH area and stratified into four groups (32 in each) according to their BMI. Those who were pregnant, breast feeding, or on long-term medications were excluded. Body weight and height, hip circumference (HC) and waist circumference (WC) were measured, using standard protocols. Lean and fat mass, were measured by DXA and percentage FM (%FM) was calculated (FM/body weight x100). Women with %FM> 30% were considered obese. RESULTS: BMI moderately correlated (r = 0.41) with %FM and BMI accounted for only 16% (r2 = 0.16) of %FM variation. Regression equations were used to estimate the cut-off values that corresponded to %FM of 30. Those cut-off values for BMI, WC, and HC were 24.4 Kg/m2, 92 cm, and 78 cm, respectively. CONCLUSION: BMI, WC and HC values of 24 kg/m2, 92 cm and 78 cm can be considered appropriate cut-off values when detecting central obesity in premenopausal women.

A framework for the development of guidelines for the management of glucocorticoid-induced osteoporosis.

UNLABELLED: This paper provides a framework for the development of national guidelines for the management of glucocorticoid-induced osteoporosis in men and women aged 18 years and over in whom oral glucocorticoid therapy is considered for 3 months or longer. INTRODUCTION: The need for updated guidelines for Europe and other parts of the world was recognised by the International Osteoporosis Foundation and the European Calcified Tissue Society, which set up a joint Guideline Working Group at the end of 2010. METHODS AND RESULTS: The epidemiology of GIO is reviewed. Assessment of risk used a fracture probability-based approach, and intervention thresholds were based on 10-year probabilities using FRAX. The efficacy of intervention was assessed by a systematic review. CONCLUSIONS: Guidance for glucocorticoid-induced osteoporosis is updated in the light of new treatments and methods of assessment. National guidelines derived from this resource need to be tailored within the national healthcare framework of each country.

Validation of psoriasis disability index (PDI) questionnaire Sinhala version.

INTRODUCTION/OBJECTIVES: Psoriasis is a chronic inflammatory dermatosis with significant physical and psychological impact leading to negative influence on the quality of life among patients with psoriasis. Other than the disease characteristics many external factors could operate in South Asian context. Lack of a reliable disease-specific instrument prevents objective estimation and monitoring of disability in patients with psoriasis and hence we aim to validate assess the psychometric properties of the Sinhala version of PDI. METHODS: A cross-sectional study conducted at dermatology clinic at a tertiary care National Hospital in Sri Lanka. Patients with psoriasis and on therapy at least 4 weeks prior to enrollment, aged more than 18 years, were included while those with already diagnosed psoriatic arthritis and/or nail psoriasis alone without any skin involvement and generalized pustular psoriasis de novo were excluded. All patients were examined by dermatologist to obtain disease characteristics. The reliability was assessed by internal consistency using Cronbach's α and item-total correlation. Convergent validity was measured with the known groups. RESULTS: Of 199 patients studied, the PDI Sinhala version showed Cronbach's α of 0.86 (all 15 items) and ranged from 0.57 to 0.77 for subscales. PDI score and Dermatology Life Quality Index (DLQI) showed good correlation of coefficient 0.76 (p < 0.01). Positive associations were noted with extent and severity of psoriasis when using sample medians (p < 0.05). The dimensionality of the PDI was determined using exploratory factor analysis and four factors were structured. CONCLUSION: The PDI Sinhala version is proved to be valid and reliable tool to assess the burden of psoriasis among Sinhala conversant patients in Sri Lanka.

Physical dependency of elderly and physically disabled; measurement concordance between 10-item Barthel index and 5-item shorter version.

INTRODUCTION: Barthel index consisting 10 items is used to estimate physical dependence of elderly and physically disabled. A shorter version with 5 items has been developed and it is more suitable as a rapid screening tool of physical dependence. OBJECTIVES: To assess the measurement agreement between 10-item Barthel index and 5-item shorter version. METHODS: The 10-item Barthel index was translated to Sinhala, adhering to the standard protocols and validated among 286 patients with varying degree of physical disability selected by stratified quota system. From the same data sheets, scores given for bathing, transfer, toileting, walking and climbing steps were used to make the shorter version. RESULTS: The 5-item Barthel index showed a high internal consistency (global Cronbach's alpha = 0.93). The 10-item version also showed a similar internal consistency (global Cronbach's alpha = 0.92) while its item-total correlations varied between 0.64- 0.90 for all items except for the urinary and bladder functions. In the factor analysis, urinary and bowel functions factored together and independent to other items and these two factors accounted for 73% variation of the score. The total scores of the 10-item and 5-item versions showed a high correlation (r = 0.9, p<0.001). In the Bland-Altman plot, more than 95% of data points were within the +/- 1.96 SD tolerance limits. CONCLUSIONS: This analysis illustrates the reliability and validity of the Sinhala version of 10-item Barthel index in estimating physical activities of daily living and the high measurement concordance between the standard 10-item and 5-item shorter versions.

Validation of Sinhala version of Psoriasis Epidemiology Screening Tool.

INTRODUCTION/OBJECTIVES: Psoriatic arthritis (PsA) occurs in one-third of patients with psoriasis and mostly remains undetected leading to debilitating deforming arthritis, eventually. The Psoriasis Epidemiology Screening Tool (PEST) is a quick and valid tool, widely used to detect PsA in clinical practice, and it has been validated to many languages. In this study, we intended to validate a Sinhala version of the PEST and assess its psychometric properties. METHODS: The Sinhala version of the questionnaire was tested on 199 patients with psoriasis attending the dermatology clinic at a tertiary care National Hospital in Sri Lanka. Patients who were detected to have PsA previously (n = 5) and those with other rheumatologic conditions (n = 12) were excluded. All patients were examined by a dermatologist, and demographic and disease characteristics were obtained. All patients were assessed by two rheumatologists who were blinded to the answers provided in the questionnaire. The diagnosis of PsA was made based on the CASPAR criteria. RESULTS: We observed the total PEST score of 3 or more to be the best cutoff value to screen for PsA. This cutoff value showed the highest Youden index (sensitivity = 0.89, specificity = 0.95). In the ROC analysis, the area under the curve of the PEST_sv was 0.95 (SE 0.02, p < 0.001). PEST_sv total score showed a significant correlation with body surface area involved but not with Dermatology Life Quality Index or Psoriasis area and severity index score. CONCLUSION: The Sinhala version of PEST demonstrated satisfactory performance as a screening tool for PsA. Key Points • Psoriatic arthritis (PsA) is the most debilitating complication of psoriasis and lack of quick, valid screening tool is a limiting factor for early identification in Sri Lankan context. • Sinhala version of the Psoriasis Epidemiology Screening Tool (PEST_sv) was tested on 199 patients with psoriasis and examined for the diagnosis of PsA according to Classification of Psoriatic Arthritis (CASPAR) criteria. • PEST_sv score of 3 or more was observed to be the best cutoff value to screen for PsA with sensitivity and specificity of 0.89 and 0.95 respectively. • PEST_sv demonstrated satisfactory performance as a screening tool for PsA.

A hospital-based study of prophylactic therapy in glucocorticoid-induced osteoporosis.

OBJECTIVE: To find out the proportion of patients who qualifies to receive prophylactic therapy for glucocorticoid-induced osteoporosis. DESIGN: Retrospective record review. Participants Current users of oral glucocorticoids referred for bone mineral density estimation to assess their fracture risk (n=134). MEASUREMENTS: Clinical history and bone mineral density of the spine and proximal femur. RESULTS: Based on the current U.K. guidelines published by the College of Physicians of London in 2002, 22 of 57 (probability of 0.39) patients under 20 years, 19 of 38 (probability of 0.5) between 20-49 years, 22 of 28 (probability of 0.79) between 50-64 years and 10 of 11 (probability of 0.9) above 64 years, qualified for the diagnosis of glucocorticoid-induced osteoporosis and prophylactic therapy was indicated for them. The prevalence of glucocorticoid-induced osteoporosis was not different between men and women in any age group. CONCLUSIONS: Due to the restricted availability of DXA scan facility, initiation of prophylactic therapy without baseline bone mineral density appears rational in current users of oral glucocorticoids older than 50 years as 80-90% of them would qualify for such therapy. However, only 40-50% of current glucocorticoids users younger than 50 years would require such therapy and simultaneous prescribing of prophylaxis appears unnecessary in 50-60% of them. Attempts should be made to estimate baseline bone mineral density in this group of patients.

Prediction of total and visceral fat contents using anthropometric measures of adiposity in women.

BACKGROUND: Although techniques such as dual energy xray absorptiometry (DXA) and quantitative CT are available to estimate global and regional adiposity, anthropometric measurements are often used to detect adiposity in clinical practice. OBJECTIVES: To assess the association between the anthropometric measurements of obesity with total and regional fat mass determined by DXA. DESIGN: A cross-sectional, descriptive study. Patients and method 106 healthy women volunteers, aged between 30 and 54 years were studied. Anthropometric measurements including body mass index (BMI), waist circumference (WC), hip circumference (HC), height adjusted WC (WC/HT), waist-hip ratio (WHR), and skin-fold thickness (SFT) over triceps, infrascapular, and iliac regions were made. All women underwent assessment of total fat mass (TFM) and visceral fat mass (VFM) using a Hologic DXA scan. RESULTS: TFM and VFM showed positive correlations with all the anthropometric measurements examined, the strongest correlation was with BMI (r = 0.89 and 0.77 for TFM and VFM respectively, p < 0.001). Correlations of TFM with WC, HC, and WC/HT were 0.72, 0.87, and 0.65, (p < 0001 for all) respectively. Corresponding figures for VFM were 0.73, 0.74, and 0.68, (p < 0001 for all). WHR showed a poor correlation with TFM (r = 18, p = 0.09) and VFM (r = 0.33, p = 0.002). SFTs measured at three sites showed less strong correlations with TFM and VFM (r = 0.48 to 0.69, p < 0.001). CONCLUSIONS: BMI has the strongest association with total and visceral fat mass among these women. Waist and hip circumferences showed high correlations with total and visceral fat mass, but adjusting waist circumference for height did not improve the correlation.

Role of Plasmapheresis and Extracorporeal Membrane Oxygenation in the Treatment of Leptospirosis Complicated with Pulmonary Hemorrhages.

INTRODUCTION: Leptospirosis is an emerging infectious disease associated with multiorgan involvement and significant morbidity and mortality. Although pulmonary hemorrhage due to leptospirosis has a high fatality, specific treatment options are limited and their efficacy is not adequately proven. We opted to find out the current evidence on plasmapheresis and extracorporeal membrane oxygenation (ECMO) in pulmonary hemorrhages due to leptospirosis. METHODS: The first search was conducted in PubMed, OVID, Google Scholar, and Cochrane clinical trial registry using keywords "leptospirosis" OR "Leptospira" OR "Weil's disease" AND "plasmapheresis" OR "plasma exchange" AND "pulmonary hemorrhage" OR "alveolar hemorrhage" OR "lung hemorrhage" and the second search was done using keyword "leptospirosis" OR "Leptospira" OR "Weil's disease" AND "ECMO" OR "Extracorporeal membrane oxygenation." The searches were not limited by study design or the date of publication. Only articles written in English were reviewed. Although we intended to include only clinical trials, it was decided later to include other information such as case reports and case series which addressed these treatment modalities. Two authors selected articles independently in a blinded manner using a set of inclusion and exclusion criteria and discrepancies were solved after discussions. RESULTS: The information found was very limited. This included one clinical trial which showed a significant survival benefit with plasmapheresis but the study design had many limitations. Two case reports described the benefit of plasmapheresis in severe leptospirosis with pulmonary hemorrhages. There were eight case reports where ECMO was performed and out of all only one patient has died. One retrospective study on patients with severe leptospirosis mentioned that four out of five patients with pulmonary hemorrhages survived after being treated with ECMO. CONCLUSIONS: Current evidence is insufficient to recommend the routine use of plasmapheresis or ECMO for patients presenting with pulmonary hemorrhages due to leptospirosis. ECMO may be a promising mode of treatment in acute respiratory failure in leptospirosis related pulmonary hemorrhages. These treatment modalities, however, can be applied based on the availability of resources and expertise at the discretion of the clinician in charge, considering patient related factors such as cardiovascular stability and derangement of coagulation profile. Clinical trials conducted adhering to standard procedures are urgently required to establish the efficacy of these treatment modalities.

FRAX® based intervention thresholds for management of osteoporosis in Singaporean women.

Potential FRAX®-based major osteoporotic fracture (MOF) and hip fracture (HF) intervention thresholds (ITs) for postmenopausal Singaporean women were explored. Age-dependent ethnic-specific and weighted mean ITs progressively increased with increasing age. Fixed ITs were derived via discriminatory value analysis. MOF and HF ITs with highest the Youden index were chosen as optimal. INTRODUCTION: We aimed to explore FRAX®-based intervention thresholds (ITs) to potentially guide osteoporosis treatment in Singapore, a multi-ethnic nation. METHOD: One thousand and one Singaporean postmenopausal community-dwelling women belonging to Chinese, Malay and Indian ethnicities underwent clinical risk factor (CRF) and BMD assessment. FRAX® major osteoporotic fracture (MOF) and hip fracture (HF) probabilities were calculated using ethnic-specific models. We employed the translational logic adopted by NOGG (UK), whereby osteoporosis treatment is recommended to any postmenopausal woman whose fracture probability based on other CRFs is similar to or exceeds that of an age-matched woman with a fracture. Using the same logic, ethnic-specific and mean weighted age-dependent ITs were computed. Employing these age-dependent ITs as a reference, the performance of fixed (age-independent) ITs were examined using ROC curves and discriminatory analysis, with the highest Youden index (YI) (sensitivity + specificity - 1) used to identify the optimal MOF and HF ITs. RESULTS: The mean age was 58.9 (6.9) years. Seven hundred and eighty-nine (79%) women were Chinese, 136 (13.5%) Indian and 76 (7.5%) Malay. Age-dependent MOF ITs ranged from 3.1 to 33%, 2.5 to 17% and 2.5 to 16% whilst HF ITs ranged from 0.7 to 17%, 0.4 to 6% and 0.4 to 6.3% in Chinese, Malay and Indian women, respectively, between the ages of 50 and 90 years. The weighted age-dependent MOF and HF ITs ranged from 2.9% and 0.6%, respectively, at the age of 50, to 28% and 14% at 90 years of age. Fixed MOF/HF ITs of 5.5%/1%, 2.5%/1% and 2.5%/0.25% were identified as the most optimal by the highest YI in Chinese, Malay and Indian women, respectively. Fixed MOFP and HF ITs of 4% and 1%, respectively, were found to be most optimal on the weighted means analysis. CONCLUSION: The ITs for osteoporosis treatment in Singapore show marked variations across ethnicities. Weighted mean thresholds may overcome the dilemma of intervening at different thresholds for different ethnicities. Choosing fixed ITs may have to involve trade-offs between sensitivity and specificity. FRAX®-based age-dependent or the fixed intervention thresholds suggested as an alternative to be considered for use in Singapore though further studies on the societal and health economic impacts of choosing these thresholds in Singapore are needed.